Take 5 for Safety Latent Errors ColliderAccelerator Department

Take 5 for Safety Latent Errors Collider-Accelerator Department 11 -17 -2009

Two Kinds of Error Active Latent

Active and Latent Errors Characteristics Who? What? When? Visible? Active front-line workers change plant state Immediate yes Latent management & staff change paper, policies, values dormant no

Anatomy of an Event Flawed Defenses Vision, Beliefs, & Values sion s i M als Go ies lic Po esses c Pro ams r Prog Vision, Beliefs, & Values Event Initiating Action Latent Organizational Weaknesses Error Precursors

Strategic Approach and Some Examples Active Errors: Anticipate and prevent active error at the job-site • • Work Planning Work Observations Latent Errors: Identify and eliminate latent organizational weaknesses • • • Safety and Risk Analyses Work Permits Procedures Check-off Lists Authorization Forms

Example of Events Related to Latent Errors § Occurrences · 2000, Electrical Overload at Linac · 2001, Siemens Failure · 2003, Transformer Dropped During Rigging · 2004, Worker Burns Hand on Heater Element in Cryogenic System · 2005, Energized Wire Discovered During RF Power Amp Repair · 2006, Arc Flash Event at STAR · 2009, Recharging a Dead Li Ion Battery · 2009, Startle Hazard at 1005 H § Critiques · RHIC Vacuum Failure at IR 12, 6 -25 -2009 · Smoldering Pipe Insulation in AGS Ring, 3 -19 -2009 · Re-evaluation of Helium Discharge Rates at RHIC, 1 -8 -2009 6